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Based on observation, document review, and interview, the facility failed to test its battery powered emergency light. This was evidenced by no testing documentation provided. This affected one of five smoke compartments and could potentially result in a delay in evacuation in the event of a power outage.

NFPA 101, 2000
19.2.9 Emergency Lighting
Emergency lighting shall be provided in accordance with section 7.9
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. A annual test shall be be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During tour, document review, and interview with staff on 8/25/15, the emergency light was observed and documents were requested.

At 2:31 p.m., the facility was observed with one battery powered emergency light at the generator location. The facility was unable to provide testing documentation for the emergency light. During an interview at 2:45 p.m., the Facility Manager stated that the facility did not have a test log for the emergency light.

Based on document review and interview, the facility failed to ensure that fire drills were held one per shift per quarter. This was evidenced by missing documentation for one fire drill training in a twelve month period. This affected five of five smoke compartments and could result in staff members being untrained and unaware of their roles and responsibilities during a fire.

Findings:

During document review and interview with staff on 8/25/15, the fire drill documents were reviewed.

At 4 p.m., the facility was missing a NOC shift fire drill for the first quarter 2015. During an interview at 4:03 p.m., the Facility Manager confirmed that documentation for the NOC shift fire drill was missing.

Based on document review and interview, the facility failed to maintain its smoke detectors. This was evidenced by incomplete smoke detector sensitivity testing and by the failure to have the smoke detectors tested for sensitivity by a certified and trained person. This affected one of five smoke compartments and could potentially result in delayed notification of a fire due to a malfunctioning or dirty smoke detector.

NFPA 101, 2000
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72, 1999
7-1.2.2 Service personnel shall be qualified and experienced in the inspection, testing, and maintenance of fire alarm systems. Examples of qualified personnel shall be permitted to include, but shall not be limited to, individuals with the following qualifications:
(1) Factory trained and certified
(2) National Institute for Certification in Engineering Technologies
fire alarm certified
(3) International Municipal Signal Association fire alarm
certified
(4) Certified by a state or local authority
(5) Trained and qualified personnel employed by an organization
listed by a national testing laboratory for the servicing
of fire alarm systems.

7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During document review and interview with staff on 8/25/15, the smoke detector sensitivity records were reviewed.

1. At 1:55 p.m., the facility had approximately 46 smoke detectors. A reviewed of the smoke detector sensitivity log indicated 43 of 46 smoke detectors were tested for sensitivity. During an interview at 2 p.m., the Facility Manager confirmed that the number of smoke detectors did not match the number tested.

2. At 2 p.m., a reviewed of the smoke detector sensitivity log indicated that the facility performed in-house smoke detector sensitivity testing. During an interview at 2:05 p.m., the Facility Manager stated that he was not trained and certified.

Based on document review and interview, the facility failed to maintain its piped in medical gas system. This was evidenced by the failure to correct discrepancies noted on the most recent medical gas inspection report. This affected one of five smoke compartments, and could potentially result in the acceleration of fire or an equipment malfunction.

Findings:

During document review and interview with Staff on 8/25/15, the medical gas report was reviewed.

At 2:21 p.m., the medical gas report dated 6/30/15, indicated that there were noted discrepancies.

The report noted the following discrepancies:
1. Need to repair leak at nitrogen pressure switch.
2. Need to repair leak at nitrous oxide outlet in Operating Room 1.
3. Need to repair two vacuum low flow rates caused by worn finish assemblies.
4. Need to replace nitrogen zone valve gauge for Operating Room 1 that was out of tolerance.
During an interview at 3 p.m., the Facility Manager stated that the facility had just received the medical gas report via email and had not receive the hard copy yet.

Based on document review and interview, the facility failed to maintain its anesthetizing locations. This was evidenced by relative humidity (RH) readings that were less than 35 percent, and by the failure to following its RH policy. This affected one of five smoke compartments, and could potentially result in an increased risk of fire.

Findings:

During document review and interview with staff on 8/25/15, the RH policy was reviewed.

At 2:30 p.m., the facility RH policy stated that the RH range would be kept between 35 and 60 percent. The facilities relative humidity policy stated that "Temperature and humidity are checked daily during weekdays when surgical cases are scheduled and on weekends and non-surgery scheduled days. Variances are reported to Bio-med. The actions taken for such variances will be documented on the log."
A review of the RH log indicated that in the last six month period (January-July 2015), the RH level was as low as 16% and no adjustments were documented. During an interview at 2:45 p.m., the Facility Manager stated that Bio-med would make the adjustment when it fell below 35%.
The temperature and humidity log noted that Bio-med was notified, but no adjustment were documented. The daily humidity/temperature check list indicated that, "Any temperature or humidity falling outside the normal range is to be adjusted then rechecked in 15 minutes. Bio-med will be notified of adjustment." No documentation was provided indicating that adjustment were made or rechecked in 15 minutes.
During an interview at 2:50 p.m., Facility Manager confirmed the findings.

Based on document review and interview, the facility failed to maintain the diesel generator. This was evidenced by missing one monthly full load test and three weekly inspections. This affected five of five smoke compartments, and could potentially result in a generator failure during an emergency.

NFPA 101, 2000
19.7.6 Maintenance and Testing (see 4.6.12)
4.6.12 Maintenance and Testing. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provision of this code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 110, 1999
6-4.1* Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

Findings:

During document review and interview with staff on 8/25/15, the generator records were requested.

1. At 2:10 p.m., the facility was missing one full load test in June 2015. During an interview at 2:15 p.m., the facility manager confirmed there was no full load test run for June 2015.

2. At 2:15 p.m., the facility was missing three of 53 weekly inspections in January and March 2015 and September 2014. During an interview at 2:16 p.m., the facility manager confirmed the finding.

Based on observation, the facility failed to maintain its electrical wiring and connections. This was evidenced by the use of extension cords, medical equipment plugged into power strips, and by an obstructed electrical panel. This affected four of five smoke compartments, and could potentially result in an electrical fire.

NFPA 101, 2000
19.5.1 Utilities. Utilities shall comply with the provisions of section 9.1
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, 1999
110-12 Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner.
(c) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.
110-26 Spaces About Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.
(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in.
(762 mm), whichever is greater.
400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During a tour of the facility with Staff on 8/25/15, the electrical wiring and connections were observed.

1. At 10:50 a.m., electrical panel EIA in the Soil Linen Room on the first floor was obstructed by a red and white bin that were stationed within one inch of the front of it.

2. At 11 a.m., a crash cart with a defibrillator machine and a suction canister were plugged into a mounted power strip that was connected to a extension cord, in the Recovery Room.

3. At 11:06 a.m., a fan was plugged into a orange extension cord, in the Receiving Room in the Basement.

4. At 11:13 a.m., a power strip was connected to a APC battery back-up power strip, in the outside Phone Room.

Based on observation, document review, and interview, the facility failed to test its battery powered emergency light. This was evidenced by no testing documentation provided. This affected one of five smoke compartments and could potentially result in a delay in evacuation in the event of a power outage.

NFPA 101, 2000
19.2.9 Emergency Lighting
Emergency lighting shall be provided in accordance with section 7.9
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. A annual test shall be be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During tour, document review, and interview with staff on 8/25/15, the emergency light was observed and documents were requested.

At 2:31 p.m., the facility was observed with one battery powered emergency light at the generator location. The facility was unable to provide testing documentation for the emergency light. During an interview at 2:45 p.m., the Facility Manager stated that the facility did not have a test log for the emergency light.

Based on document review and interview, the facility failed to ensure that fire drills were held one per shift per quarter. This was evidenced by missing documentation for one fire drill training in a twelve month period. This affected five of five smoke compartments and could result in staff members being untrained and unaware of their roles and responsibilities during a fire.

Findings:

During document review and interview with staff on 8/25/15, the fire drill documents were reviewed.

At 4 p.m., the facility was missing a NOC shift fire drill for the first quarter 2015. During an interview at 4:03 p.m., the Facility Manager confirmed that documentation for the NOC shift fire drill was missing.

Based on document review and interview, the facility failed to maintain its smoke detectors. This was evidenced by incomplete smoke detector sensitivity testing and by the failure to have the smoke detectors tested for sensitivity by a certified and trained person. This affected one of five smoke compartments and could potentially result in delayed notification of a fire due to a malfunctioning or dirty smoke detector.

NFPA 101, 2000
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72, 1999
7-1.2.2 Service personnel shall be qualified and experienced in the inspection, testing, and maintenance of fire alarm systems. Examples of qualified personnel shall be permitted to include, but shall not be limited to, individuals with the following qualifications:
(1) Factory trained and certified
(2) National Institute for Certification in Engineering Technologies
fire alarm certified
(3) International Municipal Signal Association fire alarm
certified
(4) Certified by a state or local authority
(5) Trained and qualified personnel employed by an organization
listed by a national testing laboratory for the servicing
of fire alarm systems.

7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During document review and interview with staff on 8/25/15, the smoke detector sensitivity records were reviewed.

1. At 1:55 p.m., the facility had approximately 46 smoke detectors. A reviewed of the smoke detector sensitivity log indicated 43 of 46 smoke detectors were tested for sensitivity. During an interview at 2 p.m., the Facility Manager confirmed that the number of smoke detectors did not match the number tested.

2. At 2 p.m., a reviewed of the smoke detector sensitivity log indicated that the facility performed in-house smoke detector sensitivity testing. During an interview at 2:05 p.m., the Facility Manager stated that he was not trained and certified.

Based on document review and interview, the facility failed to maintain its piped in medical gas system. This was evidenced by the failure to correct discrepancies noted on the most recent medical gas inspection report. This affected one of five smoke compartments, and could potentially result in the acceleration of fire or an equipment malfunction.

Findings:

During document review and interview with Staff on 8/25/15, the medical gas report was reviewed.

At 2:21 p.m., the medical gas report dated 6/30/15, indicated that there were noted discrepancies.

The report noted the following discrepancies:
1. Need to repair leak at nitrogen pressure switch.
2. Need to repair leak at nitrous oxide outlet in Operating Room 1.
3. Need to repair two vacuum low flow rates caused by worn finish assemblies.
4. Need to replace nitrogen zone valve gauge for Operating Room 1 that was out of tolerance.
During an interview at 3 p.m., the Facility Manager stated that the facility had just received the medical gas report via email and had not receive the hard copy yet.

Based on document review and interview, the facility failed to maintain its anesthetizing locations. This was evidenced by relative humidity (RH) readings that were less than 35 percent, and by the failure to following its RH policy. This affected one of five smoke compartments, and could potentially result in an increased risk of fire.

Findings:

During document review and interview with staff on 8/25/15, the RH policy was reviewed.

At 2:30 p.m., the facility RH policy stated that the RH range would be kept between 35 and 60 percent. The facilities relative humidity policy stated that "Temperature and humidity are checked daily during weekdays when surgical cases are scheduled and on weekends and non-surgery scheduled days. Variances are reported to Bio-med. The actions taken for such variances will be documented on the log."
A review of the RH log indicated that in the last six month period (January-July 2015), the RH level was as low as 16% and no adjustments were documented. During an interview at 2:45 p.m., the Facility Manager stated that Bio-med would make the adjustment when it fell below 35%.
The temperature and humidity log noted that Bio-med was notified, but no adjustment were documented. The daily humidity/temperature check list indicated that, "Any temperature or humidity falling outside the normal range is to be adjusted then rechecked in 15 minutes. Bio-med will be notified of adjustment." No documentation was provided indicating that adjustment were made or rechecked in 15 minutes.
During an interview at 2:50 p.m., Facility Manager confirmed the findings.

Based on document review and interview, the facility failed to maintain the diesel generator. This was evidenced by missing one monthly full load test and three weekly inspections. This affected five of five smoke compartments, and could potentially result in a generator failure during an emergency.

NFPA 101, 2000
19.7.6 Maintenance and Testing (see 4.6.12)
4.6.12 Maintenance and Testing. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provision of this code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 110, 1999
6-4.1* Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

Findings:

During document review and interview with staff on 8/25/15, the generator records were requested.

1. At 2:10 p.m., the facility was missing one full load test in June 2015. During an interview at 2:15 p.m., the facility manager confirmed there was no full load test run for June 2015.

2. At 2:15 p.m., the facility was missing three of 53 weekly inspections in January and March 2015 and September 2014. During an interview at 2:16 p.m., the facility manager confirmed the finding.

Based on observation, the facility failed to maintain its electrical wiring and connections. This was evidenced by the use of extension cords, medical equipment plugged into power strips, and by an obstructed electrical panel. This affected four of five smoke compartments, and could potentially result in an electrical fire.

NFPA 101, 2000
19.5.1 Utilities. Utilities shall comply with the provisions of section 9.1
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, 1999
110-12 Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner.
(c) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.
110-26 Spaces About Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.
(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in.
(762 mm), whichever is greater.
400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During a tour of the facility with Staff on 8/25/15, the electrical wiring and connections were observed.

1. At 10:50 a.m., electrical panel EIA in the Soil Linen Room on the first floor was obstructed by a red and white bin that were stationed within one inch of the front of it.

2. At 11 a.m., a crash cart with a defibrillator machine and a suction canister were plugged into a mounted power strip that was connected to a extension cord, in the Recovery Room.

3. At 11:06 a.m., a fan was plugged into a orange extension cord, in the Receiving Room in the Basement.

4. At 11:13 a.m., a power strip was connected to a APC battery back-up power strip, in the outside Phone Room.